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U.S. Safety Net
Kim: Safety net health systems provide essential care to low-income individuals in the United States, including those that are uninsured. The Affordable Care Act (ACA) greatly reduced the number of individuals who were uninsured, but an estimated 28 to 31 million Americans will continue to lack full health coverage, even with ACA in place (Choksi, Chang, Wilson, 2017). Inpatient, emergency, and ambulatory services for this population are provided by safety-net health systems. The Institute of Medicine (IOM), define safety-net providers as individuals who by mission or mandate offer access to care despite a patient’s inability to pay. Their patient population includes uninsured, Medicaid, and other vulnerable individuals. The safety net health system encompasses public hospitals, community health centers, and providers of specialized services, such as school-based clinics (Choksi, Chang, Wilson, 2017). A decreased number of uninsured adults is the biggest effect the ACA has had on the U.S. safety net. From 2010 to 2016 the number of uninsured adults dropped by 20 million. These drops have been driven by Medicaid expansion, health insurance marketplaces, employer mandates to provide insurance, and a provision permitting young adults to remain on their parent’s insurance until age 26 (Choksi, Chang, Wilson, 2017). Early analysis of the financial benefit to hospitals associated with ACA coverage has been an overall decrease in uncompensated care from $34.9 billion to $28.9 billion in 2014 nationwide (Choksi, Chang, Wilson, 2017). With these decreases, the ACA has included provisions that reduce Medicaid and Medicare Disproportionate Share Hospital (DSH) allotments, which provide supplementary income to hospitals that treat underinsured and uninsured patients. These reductions which began in 2014 would estimate a total of $22.1 billion by fiscal year 2019 (Choksi, Chang, Wilson, 2017). These reductions put the safety net and its providers in danger because even with the full implementation of the ACA coverage expansions, an estimated 28 million people will continue to be uninsured, relying on the safety net for care. With decreased federal payments for uncompensated care and the millions of people who will continue to be uninsured, the unmet costs for safety net care is estimated to be between $1.38 billion and $1.54 billion by 2019 (Choksi, Chang, Wilson, 2017). Safety net providers that are in non-expansion states face further risk of reductions in federal payments, such as DSH allotments for uncompensated care, despite having a large share of uninsured patients. For example, in Texas, not only do they risk federal reductions but also state reductions in Medicaid DSH allocations (Choksi, Chang, Wilson, 2017). Other threats to the health care safety net include Congress’s continued efforts to repeal key parts of the ACA through versions of the Graham-Cassidy proposal and other efforts. Also, there is continued talks by high members of the government such as Speaker Paul Ryan about legislative efforts to reform Medicaid, Medicare, and safety net programs, cutting these programs to low-income Americans. These reforms could include smaller proposals such as work requirements for Medicaid, nutrition programs, and housing assistance (Still Lurking: Federal Threats to Health Care, 2018). ☀